列线图模型在高血压患者原发性醛固酮增多症筛查中的效能

Efficacy of nomogram model on screening primary aldosterone in hypertensive patients

目的观察血钾、SUSPPUP指数、PFK评分及包含性别、血钾、钙磷乘积、尿液pH值建立的列线图模型在高血压患者原发性醛固酮增多症(PA)的筛查中的效能,探讨其与醛固酮肾素比值(ARR)筛查结果的一致性。方法2010年1月—2014年1月新疆维吾尔自治区人民医院诊治高血压患者937例,均于入院次日测定血钾、血钠、血钙水平及坐位血浆肾素活性及醛固酮,计算钙磷乘积、ARR;收集患者24 h尿液,测定尿钠、钾水平,计算SUSPPUP指数;应用pH试纸检测患者清晨尿液pH值。分别采用血钾(<3.5 mmol/L为阳性)、SUSPPUP指数[>5.3(mmol/L)^(-1)为阳性]、PFK评分(>2分为阳性)、列线图模型(>21%为阳性)、ARR[≥20(ng·dL^(-1))/(μg·L^(-1)·h^(-1))为阳性]筛查PA。ARR筛查阳性者行盐水负荷试验诊断PA。绘制ROC曲线评估血钾、SUSPPUP指数、PFK评分、列线图模型筛查PA的效能,采用Kappa检验评价其与ARR筛查结果的一致性。结果937例患者中血钾筛查阳性168例,SUSPPUP指数筛查阳性44例,PFK评分筛查阳性120例,列线图模型筛查阳性314例,ARR筛查阳性422例。ARR筛查阳性患者中165例确诊PA。血钾、SUSPPUP指数、PFK评分、列线图模型分别以3.5 mmol/L、5.3(mmol/L)^(-1)、2分、21%为最佳截断值,筛查高血压患者PA的AUC分别为0.61(95%CI:0.56~0.66,P<0.001)、0.52(95%CI:0.47~0.57,P=0.479)、0.57(95%CI:0.52~0.62,P=0.005)、0.62(95%CI:0.57~0.67,P<0.001),灵敏度分别为36%、7%、24%、53%,特异度分别为86%、96%、90%、70%。列线图模型筛查高血压患者PA的灵敏度高于血钾、SUSPPUP指数、PFK评分(χ^(2)=60.612,P<0.001;χ^(2)=4.915,P=0.025;χ^(2)=36.831,P<0.001)。列线图模型、PFK评分筛查高血压患者PA与ARR一致性均较好(Kappa=0.122,P<0.001;Kappa=0.092,P<0.001),血钾、SUSPPUP指数筛查高血压患者PA与ARR一致性均较差(Kappa=0.047,P<0.001;Kappa=0.002,P<0.001)。结论包含性别、血钾、钙磷乘积、尿液pH值的列线图模型筛查高血压患者PA的灵敏度较高,列线图模型以>21%为阳性时筛查高血压患者PA与ARR一致性较好。

Objective To observe the efficacies of serum potassium,SUSPPUP ratio,PFK score,and nomogram model including gender,serum potassium,calcium-phosphorus product and urine pH value on screening primary aldosteronism(PA)in hypertensive patients,and to explore the consistencies of the above indexes with aldosterone-renin ratio(ARR).Methods From January 2010 to January 2014,937 hypertensive patients were diagnosed and treated in People's Hospital of Xinjiang Uygur Autonomous Region.The serum potassium,sodium,calcium,plasma sitting renin activity and aldosterone were detected the next day after admission,and the calcium-phosphorus product and ARR were calculated.The 24 h urine was collected and the urine patassium and sodium levels were detected.The SUSPPUP ratio was calculated.The pH value of urine was detected by pH test paper in the morning.Taking serum potassium<3.5 mmol/L,SUSPPUP ratio>5.3(mmol/L)^(-1),PFK score>2,nomogram model>21%,and ARR≥20(ng·dL^(-1))/(μg·L^(-1)·h^(-1))as the positive values,PA was screened.The patients with positive ARR were confirmed as PA by using saline load test.ROC curves were plotted to evaluate the efficiencies of serum potassium.SUSPPUP ratio,PFK score and nomogram model on screening PA.Kappa test was used to evaluate its consistency with ARR screening results.Results In 937 patients,serum potassium was positive in 168,SUSPPUP ratio was positive in44,PFK score was positive in 120,nomogram model was positive in 314,and ARR was positive in 422.In positive ARR patients,PA was confirmed in 165 patients.When the optimal cut-off values of serum potassium,SUSPPUP ratio,PFK score and nomogram model were 3.5 mmol/L,5.3(mmol/L)^(-1),2 and 21%,the AUCs for predicting PA in hypertensive patients were 0.61(95%CI:0.56-0.66,P<0.001),0.52(95%CI:0.47-0.57,P=0.479),0.57(95%CI:0.52-0.62,P=0.005)and 0.62(95%CI:0.57-0.67,P<0.001),the sensitivities were 36%,7%,24%and 53%,and the specificities were 86%,96%,90%and 70%,respectively.The sensitivity of nomogram model was higher than that of serum potassium.SUSPPUP ratio and PFK score(χ^(2)=60.612,P<0.001;χ^(2)=4.915,P=0.025;χ^(2)=36.831.P<0.0013),Nomogram model and PFK score showed a high consistency with ARR(Kappa=0.122.P<0.001;Kappa=0.092,P<0.001),and serum potassium and SUSPPUP ratio showed a low consisteucy with ARR(Kappa=0.047,P<0.001;Kappa=0.002,P<0.001)to screen PA in hypertensive patients.Conclusion The nomogram model,which includes gender,serum potassium,calcium-phosphorus product and urine pH value,is more sensitive to predict PA in hypertensive patients,and has a high consistency with ARR when the nomogram model>21%is taken as the positive value.